About the pathway
The End-of-Life Pathway supports older people who have 3 months or less to live and want to remain at home.
Older people who want to access this pathway must meet eligibility criteria as assessed by a doctor or nurse practitioner.
Funding
Around $25,000 is available per participant over a 12-week period.
If a participant still needs services after 12 weeks, they may:
- continue using the budget up until the 16-week mark, if funding is still available
- access unspent Home Care Package funds, if available
- work with their provider to request a Support Plan Review to move to an ongoing Support at Home classification.
Eligibility for the pathway
Older people are eligible for the End-of-Life Pathway if they meet both of the following criteria:
- a doctor or nurse practitioner estimates their life expectancy as 3 months or less
- they scored 40 or lower on the Australian-modified Karnofsky Performance Status (AKPS).
A doctor or nurse practitioner must capture this information in the End-of-Life Pathway Form when completing it with an older person.
End-of-Life Pathway – fact sheet for doctors and nurse practitioners
Accessing the pathway
The End-of-Life Pathway is open to existing and new Support at Home participants.
Existing Support at Home participants
If eligible, existing Support at Home participants can request an urgent Support Plan Review to transition to the pathway. They will need to:
- Discuss and complete the End-of-Life Pathway Form alongside a doctor or nurse practitioner.
- Pass on the completed form to their provider.
- Request an urgent Support Plan Review, either by:
- asking their provider to submit a request through the My Aged Care Service and Support Portal
- contacting My Aged Care.
- Have an aged care assessor complete the review and assess eligibility.
- Receive a new Notice of Decision and support plan. You accept the referral in the My Aged Care Service and Support Portal and notify Services Australia.
- Work with their care partner to plan care and services that complement other palliative care services.
It is not recommended that participants change provider if they want to access the End-of-Life Pathway. While it is possible to do this, it may delay access to services.
New Support at Home participants
Older people who are not currently accessing Support at Home and would like to access the End-of-Life Pathway can be referred for an aged care assessment.
They will need to:
- Discuss and complete the End-of-Life Pathway Form alongside a doctor or nurse practitioner and request a high-priority aged care assessment.
- Discuss eligibility with a medical professional who can then initiate an online referral for an assessment or give the person a hard copy of the completed form.
- Apply for an assessment online or by contacting My Aged CareMy Aged Care.
- Have an aged care assessment to determine eligibility and services they need.
- Once approved, receive a Notice of Decision and a support plan.
- Choose a provider and have them accept the referral in the My Aged Care Service and Support Portal.
- Enter into a service agreement and begin receiving care and services that complement other palliative care services.
What services you can deliver
End-of-Life Pathway participants can access services approved in their Notice of Decision and support plan, in line with the service list.
Participants may be able to access some assistive technology funding (low and medium tiers) but cannot receive funding for home modifications. Learn more about the Assistive Technology and Home Modifications (AT-HM) scheme.
Relevant participants can also access Aboriginal and Torres Strait Islander health workers or practitioners on this pathway, in addition to support to engage in cultural activities.
Learn more about Support at Home services.
Care management
Care partners must deliver care management activities to all participants.
Care partners should collaborate on a care plan with the participant and their family or supporters.
In addition to standard activities, care partners should ensure that there is communication and coordination between the participant’s medical team, their family or supporters, and any other palliative care services.
Unlike ongoing services, you claim care management against a participant’s End-of-Life funding account. There is no cap on what can be claimed for care management under the End-of-Life Pathway. Care management amounts should be agreed between the provider and participant, and proportionate and in the participant’s best interests.
Learn more about care management.
Accessing other palliative care services
Participants will likely need specialist palliative care services to remain at home.
The Australian Government funds palliative care services in every state and territory. The End-of-Life Pathway is designed to complement but not fund these services.
For example, a participant may access specialist palliative care nurses and medication management through a state-based program while using the End-of-Life Pathway to get meals and personal care services.
A list of state and territory based palliative care schemes is available in Chapter 15 of the Support at Home program manual.
Participant contributions
Participants must contribute to the cost of their independence and everyday living services. Their contribution level is based on an income and assets assessments.
Clinical supports, like nursing care, are fully funded by the government. You cannot ask participants to contribute to these services.
Learn more about participant contributions.
Exiting the pathway
Participants may exit the pathway when:
- they no longer want to stay at home or are unable to do so
- the period of funding for the End-of-Life Pathway has finished (maximum 16 weeks).
If they need further services beyond the funding period, you can request a Support Plan Review for the participant to move to an ongoing classification.
A participant is also considered to exit the pathway when they pass away. Their family or supporters should notify you, ideally in writing. You should then notify Services Australia. You will have 60 days to finalise any claims with Services Australia.
Resources
You may find these resources helpful:
- Our palliative care webpage has useful information.
- The Program of Experience in the Palliative Approach (PEPA) is available to aged care workers, which includes a Learning Guide for Workers about planning and assessing palliative care needs.
- The End of Life Directions for Aged Care (ELDAC) project helps aged care providers and GPs improve their palliative care and advance care planning skills.
- palliAGED has information for older people, families, friends and carers.
- Palliative Care Australia has information for providers, older people, families, friends and carers, including a National Service Directory.
If you offer End-of-Life Pathway services to older Aboriginal or Torres Strait Islander peoples, you may find these resources helpful:
- Palliative Care Australia’s Aboriginal and Torres Strait Islander resources
- Gwandalan’s modules, resources and webinars for palliative and end-of-life care
- Indigenous Program of Experience in the Palliative Care Approach (IPEPA).
You may also choose to provide the Guide to End-of-Life Pathway booklet to older people who want to access the pathway and their families, friends, or carers.
Find out more
Read:
- Chapter 15 (End-of-Life Pathway) in the Support at Home program manual
- End-of-Life Pathway fact sheet for participants.